Pelvic Fragility Fractures

Abstract

Background: Osteoporosis is often undiagnosed until patients experience fragility fractures. Pelvic fractures are common but underappreciated sentinel fractures. Screening patients with a pelvic fracture for osteoporosis may provide an opportunity to initiate appropriate treatments such as anti-osteoporosis therapy to prevent additional fractures. Methods: This retrospective cohort review examined the management of osteoporosis after pelvic fractures at a large tertiary care center without an established secondary fracture prevention program. Data were extracted from electronic medical records of all new patients with a pelvic fracture who were ≥50 years of age from this center and its affiliated community hospitals from 2008 to 2014. Outcome measures included the initiation of anti-osteoporosis therapy before the fracture, within the year following the fracture, >1 year following the fracture, or never and new osteoporotic fractures within 2 years after a pelvic fracture. Results: From 2008 to 2014, 947 patients presented with pelvic fractures. Of these patients, 27.1% (257 patients) were taking anti-osteoporosis medications before the fracture. Four percent of treatment-naïve patients began anti-osteoporosis therapy within 1 year of fracture, with 1.2% (11 patients) starting after 1 year. Of the treatment-naïve patients, 92.3% (637 patients) were never prescribed anti-osteoporosis therapy. Treatment rates were consistent over time. Within 2 years, 41.0% (388 patients) developed fragility fractures at secondary sites: 12.0% (114 patients) experienced a hip fracture, and 16.4% (155 patients) experienced a vertebral fracture. Conclusions: Osteoporosis screening and initiation of secondary fracture prevention after a pelvic fracture were inadequate in the study population. Of the patients in this study, 909 (96.0%) never underwent a dual x-ray absorptiometry (DXA) scan during the study period. Of the 690 treatment-naïve patients, 637 (92.3%) were never administered anti-osteoporosis medications. Within 2 years, 41.0% of all patients developed additional osteoporotic fractures. This study demonstrates an opportunity to improve bone health by screening for and treating osteoporosis in patients with a pelvic fragility fracture. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High prevalence of missed information related on bone health in orthogeriatric patients with fragility fractures of the pelvis—an institutional register-based analysis

“…The first key finding shows that only little attention was paid on genesis of the fragility fractures during inpatient stay. The small number of patients screened for vitamin D deficiency and/or examined via DXA measurement is also common and known from other studies; Smith et al presented in a recent cohort review that in 947 pelvic fragility fracture patients, 90.8% never received a DXA scan (before and after fracture) and 67.3% never received medication for osteoporosis during their study period [20]. Considering the initially mentioned increase in the geriatric population and following increase in fragility fractures, improving this diagnostic lack is of utmost importance for secondary fracture prevention.…”

“…Besides osteoporosis, osteomalacia also has to be considered cause for fragility fractures of the pelvis, but remains neglected in most of the cases or misdiagnosed as osteoporosis. Since only patients aged 80 years and older were included, this differentiates the present study from preexisting literature, where usually a younger cohort was evaluated with lower prevalence of osteomalacia [20]. As fragility, frailty, sarcopenia, and subsequent osteomalacia intensify with advancing age, this is a major strength of the present study, because the most vulnerable cohort is appropriately represented.…”

Sacral Insufficiency Fractures

“…At the time of diagnosis, up to 80% of patients with an SIF have other fragility fractures 7-9,12 . The most common fractures are obturator ring fractures, vertebral fractures, and intertrochanteric femoral fractures 3,7-9,12 .…”

“…SIFs were first described in a 1982 case report as spontaneous osteoporotic fractures of the sacrum 2 . Despite many publications further chronicling SIF, this pathology continues to be underdiagnosed and undertreated 40 years later [3][4][5][6][7][8] . SIFs have been described as an evolving epidemic characterized by inadequate diagnosis, leading to a prolonged and limited recovery 9 .…”

“…The treatment of underlying osteoporosis and the prevention of future fracture are pivotal components of nonoperative treatment. Smith et al recently illuminated the inadequacy of osteoporotic treatment prior to and following pelvic fragility fractures 3 . In a cohort of 947 patients, 90% never underwent a dual x-ray absorptiometry (DXA) scan, and 92% were never treated with bone-directed medications.…”